Increasing Access to Medication-Assisted Treatment for Opioid Use Disorders

Estimating Costs, Supply, and the Effects of Insurance Expansions

by Ervant J. Maksabedian Hernandez

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Drug overdose deaths in America exceeded 50,000 in 2015, claiming more lives annually than gun violence and motor vehicle accidents. Of these, more than 63% of overdose deaths were due to opioids. Medication-assisted treatment is regarded as the most effective form of treatment for those struggling with an opioid use disorder. However, medication costs and insurance coverage remain identified barriers to treatment.

My dissertation measures access to buprenorphine, the fastest growing form of medication-assisted treatment, and the effects of demand side interventions aiming to tackle the opioid problem in America. While some supply side interventions have mixed effectiveness or unintended consequences potentially exacerbating the problem, demand side interventions may be more effective in reducing overall demand for opioids and opioid-related deaths. Insurance expansions, such as the federal insurance parity law of 2008 or the 2014 Medicaid expansions associated with the Affordable Care Act, could have increased access to treatment.

The three main insights from this dissertation are: 1) who pays for the medication matters when considering the average cost of buprenorphine maintenance treatment. Patients with public insurance have lower buprenorphine costs compared to those paying with cash-only or with commercial insurance. 2) The federal parity law for substance use disorders (MHPAEA) did not increase access to medication-assisted treatment for opioid use disorders. 3) Out-of-pocket costs for prescription opioids have decreased dramatically while costs for buprenorphine have not declined at similar pace, thus complicating access for those with an opioid use disorder.

Efforts by Congress to push commercial insurers to expand coverage for addiction services have not led to lower costs for opioid treatment, unlike the experience among those with public insurance. Policymakers need to look for other ways to get commercial insurers to lower costs, particularly if further health care reform leads to a reduction in Medicaid funding and enrollment.

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This document was submitted as a dissertation in August 2017 in partial fulfillment of the requirements of the doctoral degree in public policy analysis at the Pardee RAND Graduate School. The faculty committee that supervised and approved the dissertation consisted of Rosalie Liccardo Pacula (Chair), Priscilla Hunt, David Powell, and Harold Pollack.

This report is part of the RAND Corporation dissertation series. Pardee RAND dissertations are produced by graduate fellows of the Pardee RAND Graduate School, the world's leading producer of Ph.D.'s in policy analysis. The dissertations are supervised, reviewed, and approved by a Pardee RAND faculty committee overseeing each dissertation.

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